Arizona Senior Life, LLC

Based on observation, interview, and record review, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for two of three caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. Upon arriving at the facility around 8:30 am, the Compliance Officer observed E2, E3, and E4 working at the facility, and E2, E3, and E4 identified themselves as caregivers. 2. In an interview, the compliance asked E2 when E2 and E3 had first arrived in Arizona. E2 reported that E2 and E3 arrived in Arizona in 2019 and have worked at the facility as caregivers since May 2025. 3. A review of E2's personnel record revealed an employment application that indicated E2 worked as a caregiver. Upon further review of E2 personnel records, a caregiver certificate dated 2010 was revealed. 4. A review of E3's personnel record revealed an employment application that indicated E3 worked as a caregiver. Upon further review of E3 personnel records, a caregiver certificate dated 2010 was revealed. 5. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113, for one of four residents reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A stated, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual’s freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R2's medical records revealed no documentation of a completed "TB Screening and Risk Assessment Forms" and no documentation of freedom from infectious tuberculosis. Based on R2's dates of admission, this documentation was required. 3. In an interview, E1 acknowledged the manager failed to ensure that R2 provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113.

Based on record review and interview, the manager failed to ensure a medical record was maintained for one of four residents in the facility. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A request for R4’s medical record revealed that the facility had no medical record available for review at the time of inspection. 2. In an interview, E1 and E5 acknowledged that R4 was a resident at the facility. 3. In an exit interview, the findings were reviewed with E1 and E5, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a medical record was established and maintained for one of four sampled residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. A request for R4’s medical record revealed the facility had no medical record available for review for E4. 2. In an interview, E1 reported that the facility had no medical record for E4. 3. In an exit interview, the findings were reviewed with E1 and E4, and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed a medication cabinet in the dining kitchen area, which contained medication for five residents at the facility. The medication cabinet was unlocked at the time of inspection. 2. In an interview, E1 and E4 acknowledged that the medication cabinet was unlocked and the medication in the cabinet was accessible to residents at the facility.

Based on record review, documentation review and interview, the manager failed to ensure a personnel record for employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties; the individual's education and experience applicable to the individual's job duties; the individual's completed orientation required by policies and procedures; the individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) and (C). Findings include: 1. In an interview, E3 reported to have been recently hired by the facility as a caregiver. 2. A review of personnel records revealed a personnell record for E3 was not available for review. 3. In an interview, E4 reported E3 was an employee at another facility E4 "oversaw." E4 indicated E3 was at the facility to complete some maintenance tasks for one day only. 4. A review of an email from E4, on September 26, 2023 at 10:45 a.m., revealed a copy of E3's fingerprint clearance card, evidence of freedom from infectious tuberculosis, and evidence of completed cardiopulmonary resuscitation and first aid training. 5. In an interview, E4 was unaware it was necessary to maintain a personnel record for E3 because E3 was not interacting directly with residents.